Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birkwood Village Of Fort Madison during CMS and state inspections, most recent first.
Unsafe Food Handling During Meal Prep and Service: A cook repeatedly used the same gloves while handling bread, milk, menus, utensils, cooked chicken, potatoes, and equipment during prep and plating. The cook touched food and nonfood surfaces throughout the meal process, including during temp checks and while serving 30 of 51 plated meals. Staff interviews confirmed this was not acceptable because of cross contamination concerns, and the facility policy required safe hygienic practices and appropriate glove use.
A resident’s room was not cleaned daily, and repeated observations showed debris on the floor, smudges on the bedside table, and an urinal left on the floor. The resident, who had intact cognition, said housekeeping had not cleaned the room for about a week and that a CNA had to clean it with a broom and dustpan. CNAs and housekeeping staff gave inconsistent accounts of who was responsible for cleaning the room, with staff stating the room was only cleaned intermittently or when the resident showered.
A resident with an indwelling catheter, bowel incontinence, a Stage IV sacrococcygeal pressure ulcer, additional deep tissue injuries, and moisture-related rashes under the breasts and in the peri area required multiple ordered treatments, including wound cleansing and dressing, antifungal cream, and nephrostomy tube site care. During an observed care episode, an RN repeatedly changed gloves between cleaning bowel, performing coccyx wound care, applying topical treatments to the thigh, breast, and groin, and completing nephrostomy tube site care, but did not perform hand hygiene between glove changes, contrary to the facility’s hand hygiene policy requiring hand hygiene before donning and after removing gloves.
Surveyors identified failures in food labeling, storage, and sanitation, including opened containers of tuna and chicken salad kept beyond the facility's five-day limit, dust accumulation on the ice machine filter, improper storage of a styrofoam scoop in a sugar bin, and a dietary staff member preparing pureed food without a beard restraint.
Two residents were not provided with the required NOMNC (CMS-10123) when their Medicare Part A skilled services ended after meeting therapy goals. Instead, only the SNF ABN (Form 10055) was issued, due to staff confusion and lack of proper training on notification requirements. The facility also lacked a policy for beneficiary notifications.
A resident with severe cognitive impairment and multiple mental health diagnoses did not have their care plan updated to include required PASRR Level II specialized services, such as psychiatric medication management and supportive counseling. Staff interviews confirmed that these services were not initiated and the care plan lacked necessary interventions.
A resident with diagnoses of Parkinsonism, depression, and PTSD had a care plan that did not specify the reasons or triggers for PTSD, despite being cognitively intact and receiving medication for the condition. Staff interviews revealed a lack of knowledge about the resident's PTSD triggers, and the care plan only included general interventions without individualized details.
A resident with a history of constipation, diabetes, and end stage renal disease experienced multiple episodes of no bowel movement for several days, during which PRN medications were not consistently administered and staff responses varied. The facility did not have a formal bowel management protocol, leading to delays in intervention and inconsistent care for constipation.
Nursing staff responsible for wound care and wound VAC application for a resident with complex medical needs did not have formal training or competency verification. The LPN performing these tasks relied on self-directed learning, and facility leadership confirmed there was no designated, formally trained wound care nurse or policy for wound care or wound VAC use.
Two residents with diabetes received insulin injections despite physician orders to hold the medication if blood sugar was less than 150. Nursing staff administered insulin on multiple occasions when blood sugar readings were below the specified threshold, and staff interviews revealed confusion or disregard for the prescribed parameters. The facility lacked a policy to guide medication administration in these cases.
A resident experienced severe complications due to improper catheter management at a facility. After a routine catheter change, the resident had little to no urine output and bloody urine for several days. The facility failed to promptly address these symptoms, leading to a hospital diagnosis of emphysematous cystitis, acute kidney injury, and right lower lobe pneumonia. The catheter balloon was found to be incorrectly placed in the urethra, causing trauma and a UTI.
The facility failed to maintain adequate food temperatures, as observed during a survey. A resident expressed dissatisfaction with the food's taste, temperature, and appearance. Staff recorded food temperatures below the facility's policy requirements, and interviews revealed inconsistencies in understanding the required temperatures. The Dietary Manager confirmed that some food items were served below the expected temperature.
A facility failed to maintain proper infection control during medication administration when an LPN handled medications with bare hands. The LPN was observed touching Levitracetam, Pregabalin, and Calcium with Vitamin D3 tablets directly while preparing them for a resident. The Infection Preventionist and DON acknowledged the issue, but the facility's policy did not address this concern.
A resident with intact cognition reported being treated in an undignified manner by a CNA, who made derogatory comments about the resident's personal life and incontinence. The CNA refused to provide care and turned off the resident's call light, leading to feelings of intimidation and verbal abuse. The facility's investigation substantiated the abuse allegations, resulting in the CNA's termination.
A resident with intact cognition reported feeling verbally abused by a CNA over several months, with staff failing to report the incidents to management. Despite multiple staff members witnessing aggressive behavior by the CNA, including refusal to provide care and derogatory comments, the facility's abuse policy requiring immediate reporting was not followed.
A resident with Alzheimer's and impaired cognitive function experienced a swollen knee, but the facility failed to document a timely pain assessment. Despite observations of swelling, discomfort, and bruising by an RN, no pain score or treatment plan was recorded. The DON confirmed that pain should be documented in progress notes, but this was not done, leading to a deficiency in professional standards of care.
A resident with severe cognitive impairment experienced a significant weight loss of 7.16% in one month, which was not identified or addressed by the facility. The care plan required monitoring for weight loss, but the DON acknowledged that the weight loss did not trigger in the facility notes and was missed by staff. The RD and DM were unaware of the issue due to a lack of alerts in the EHR system, and the facility lacked a policy on weight loss.
The facility failed to provide adequate staffing for dining assistance, as observed with two residents who had severely impaired cognitive skills and required assistance with eating. During an observation, both residents were left without assistance or food for extended periods. Staff interviews revealed that dining staffing was often inadequate, leading to delays in assisting residents. The DON was unaware of any reported concerns regarding dining staffing.
A facility failed to identify and document targeted behaviors and triggers for a resident prescribed olanzapine, leading to a deficiency in managing unnecessary medications. Despite the resident's diagnoses, the care plan lacked specific information justifying the antipsychotic use. Staff interviews revealed inconsistent documentation and care planning for the resident's behaviors, contributing to the deficiency.
Two medication errors were observed in the facility, involving residents with moderately impaired cognition. An LPN administered the wrong formulation of Senna to a resident, while an RN initially gave an incorrect dose of Lasix to another resident, later correcting it. The DON noted that staff should verify medications against the electronic health record, but this was not done, resulting in the errors.
A resident lost her dentures during a choking incident and experienced a delay in receiving dental care due to the facility's inability to find a provider accepting state benefits. The resident, who was cognitively intact and had a history of orthopedic and heart issues, was placed on a pureed diet, leading to weight loss. The facility lacked a policy on dentures, contributing to the delay in addressing the resident's dental needs.
A resident with severely impaired cognition did not receive a straw as required by their diet order, leading to a deficiency in care. Observations showed the resident using a regular cup, and staff interviews revealed a lack of awareness and communication about the resident's need for a straw. The facility's policy on adaptive self-feeding devices was not effectively implemented, resulting in the resident not receiving the necessary assistive devices.
Facility staff failed to follow infection control practices, leading to inappropriate antibiotic use. Antibiotics were often prescribed based on symptoms without test results, causing residents to continue treatment even when cultures were negative. The Antibiotic Stewardship Policy aims to promote appropriate use, but symptom-based prescribing persisted, contributing to the deficiency.
Unsafe Food Handling During Meal Preparation and Service
Penalty
Summary
The facility failed to ensure kitchen staff followed safe food handling practices during preparation and serving of the noon meal for a census of 64 residents. During observation, a cook prepared pureed and mechanical soft meals while wearing the same gloves through multiple tasks, including handling bread, milk, menus, drawers, tongs, and cooked chicken. The cook used gloved hands to pick apart chicken, tear bread, pour milk into the Robot Coup, wipe the counter and machine, and move between tasks without changing gloves or completing hand hygiene. The cook also handled food and equipment in ways that involved repeated contact with unclean surfaces and food items. While checking temperatures, the cook used the same gloves to touch pureed chicken, ground chicken, regular baked chicken, and roasted potatoes, including putting gloved fingers into food, pinching food together, and holding pieces of chicken up while measuring temperatures. The cook also used hot pads, a thermometer, serving utensils, and trays while moving between items, and continued to touch food and serving pans during meal service. During plating, the cook touched resident menus, serving lids, tongs, spoon handles, trays, plates, and the food itself while serving 30 of 51 plated meals. The cook used one hand to place food and the other hand to keep food from rolling off the plate, and in some instances tore chicken from the bone or removed a potato from the serving pan with a gloved hand and returned it to the pan. Staff interviews confirmed that touching food with gloved hands after touching other surfaces was not acceptable and that gloves should be changed after touching different surfaces because of cross contamination concerns. The facility policy titled Food Safety Requirements stated staff would follow safe hygienic practices to prevent contamination of foods from hands and physical objects and would use gloves, tongs, deli paper, and spatulas appropriately.
Housekeeping Failed to Clean Resident Room Daily
Penalty
Summary
The facility failed to clean one resident’s room daily, and the resident stated the room had become dirty because housekeeping had not come to clean it for a week. The resident, who had a BIMS score of 13 out of 15 indicating cognition intact, reported that a CNA had to get a broom and dustpan to clean the room. The resident also stated he had been told housekeeping refused to enter the room because they had seen him exposed, although he did not know whether that was true. He further stated housekeeping cleaned only his roommate’s side of the room. Observations over several days showed the room remained uncleaned, with shoes stuck to the floor, clumps of black debris on the floor, visible smudges on the bedside table, and an empty urinal on the floor behind the head of the bed. The same debris and urinal were still present on later observations, and the floor remained unswept. CNAs stated the room was not being cleaned as often as they would like and that housekeeping had been informed. Housekeeping staff gave inconsistent accounts, with one stating he cleaned only one half of the room every once in a while and another stating she cleaned the room only when the resident took a shower. The Housekeeping Supervisor stated the room needed to be cleaned daily, was not aware the resident had been neglected, and said the housekeeper used a checklist but the resident’s room needed to be added to it.
Failure to Perform Hand Hygiene Between Glove Changes During Wound and Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during personal care, wound care, and catheter-related care for one resident. The resident had intact cognition, was dependent for toileting hygiene, required substantial/maximal assistance with rolling, used an indwelling catheter, and was always incontinent of bowel. Diagnoses included obstructive uropathy, and the resident had a Stage IV sacrococcygeal pressure ulcer requiring daily wound treatments, as well as deep tissue pressure injuries and a moisture-related rash under both breasts and in the peri area. Physician orders directed daily cleansing and dressing of the coccyx wound with Vashe solution, calcium alginate, Triad paste, and foam dressing; application of antifungal cream to the underside of both breasts and peri-area; Triad paste to left glute/thigh wounds; and skin prep and dressing changes to the nephrostomy tube site. During an observed care episode, an RN placed wound care supplies on a barrier pad on the resident’s bed and repeatedly changed gloves between multiple care tasks without performing hand hygiene in between glove changes. The RN donned gloves, handled supplies, then changed gloves without hand hygiene before cleaning bowel from the resident’s buttocks. After removing those gloves, the RN again donned clean gloves without hand hygiene to cleanse and dress the coccyx pressure ulcer. The RN then removed gloves and, without hand hygiene, donned new gloves to apply Triad cream to the back of the resident’s right thigh, followed by additional glove removal and re-donning without hand hygiene to apply antifungal cream under the right breast and to the groin area. Finally, the RN removed gloves and donned another clean pair without hand hygiene to apply skin prep and dress the nephrostomy tube site. The facility’s hand hygiene policy stated that glove use does not replace hand hygiene and that staff must perform hand hygiene prior to donning and immediately after removing gloves.
Food Safety and Sanitation Deficiencies in Dietary Department
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations. In the walk-in refrigerator, a 5-pound container of tuna salad dated 4/6 and a 5-pound container of chicken salad dated 4/4 were found, both exceeding the facility's stated five-day limit for opened items. The ice machine in the kitchen had visible dust on its air filter, despite posted instructions to clean the filter twice a month, and this dust was observed on two separate occasions. Additionally, a styrofoam scoop was found stored in a clear plastic bin containing sugar. During food preparation, a dietary staff member with facial hair on the side of the face and above the lip was observed preparing pureed food without using a beard restraint. The Dietary Manager confirmed that opened food items should be labeled with the open date and discarded after five days, as per facility policy, but this was not followed for the items observed.
Failure to Issue Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, to two residents who were ending their Medicare Part A skilled services after meeting their therapy goals and returning to baseline independence. In both cases, the residents received the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), Form 10055, but not the NOMNC, which is mandated to inform beneficiaries that Medicare coverage is ending and to provide information on how to appeal the decision. Documentation reviews confirmed that the NOMNC was not issued, and staff indicated they were unaware that both forms were required. Interviews with the Social Worker revealed confusion regarding the correct forms to use, as she had only completed the SNF ABN and was not properly trained on the NOMNC process. The Social Worker began handling beneficiary notifications when the MDS Coordinator went on leave and acknowledged insufficient training from the previous Administrator. The Administrator was unaware of the error until it was brought to their attention, and the Nurse Consultant confirmed that the facility did not have a policy in place regarding beneficiary notifications.
Failure to Update Care Plan and Initiate PASRR Level II Specialized Services
Penalty
Summary
The facility failed to update the care plan and initiate specialized services for a resident as required by the PASRR Level II determination. Clinical record review and staff interviews revealed that the resident, who had severely impaired cognition, moderate intellectual disabilities, and an unspecified mood disorder, was prescribed antipsychotic, antianxiety, and anticonvulsant medications. The PASRR Level II outcome specified the need for ongoing psychiatric medication management by a psychiatrist or psychiatric ARNP, as well as facilitation of family involvement and supportive counseling from facility staff. However, the care plan lacked a focus area and interventions to address these specialized services. Interviews with facility staff, including the social worker, MDS coordinator, and DON, confirmed that the care plan had not been updated to reflect the PASRR Level II requirements. The social worker initially believed that psychiatric services were already in place, but later acknowledged that the resident had not received such services since admission. The DON also confirmed that the care plan should have been updated and that the facility had not addressed the PASRR Level II prior to the survey date. The facility did not have a policy related to PASRRs and relied on CMS regulations.
Failure to Address PTSD Triggers and Reasons in Care Plan
Penalty
Summary
The facility failed to adequately address the reason and trigger areas for a resident's diagnosis of post-traumatic stress disorder (PTSD) as part of the care planning process. Clinical record review showed that the resident had diagnoses including Parkinsonism, depression, and PTSD, with a care plan that only included general interventions such as reporting traumatic reactions to the provider or charge nurse. The care plan did not specify the resident's PTSD triggers or the underlying reason for the diagnosis, despite the resident being cognitively intact and on medication for PTSD. Interviews with facility staff, including the RN, MDS Coordinator, ADON, and DON, revealed a lack of knowledge regarding the resident's PTSD triggers and the specific reason for the diagnosis. Staff were unable to provide details about the resident's traumatic reactions or triggers, and the care plan was not individualized to address these aspects. Additionally, the facility did not have a policy related to care plans and relied on CMS regulations for guidance.
Failure to Ensure Timely Follow-Up for Constipation Management
Penalty
Summary
A deficiency was identified when a resident with a history of constipation, diabetes mellitus type 2, and end stage renal disease did not receive timely follow-up for constipation despite not having a bowel movement for multiple days. The resident was cognitively intact and had a care plan in place that included monitoring bowel movements every shift, administering medications as ordered, and reporting signs and symptoms of complications related to constipation. The resident was prescribed both scheduled and PRN medications for constipation, and was also receiving opioid pain medications, which can contribute to constipation. Record review showed several periods where the resident went multiple days without a documented bowel movement, specifically from 4/4 to 4/9, 4/13 to 4/17, and 4/19 to 4/22. During these periods, PRN medications were not consistently administered according to the facility's stated practice of intervening after three days without a bowel movement. For example, on some days when the resident had not had a bowel movement for several days, no PRN medication was given, and the resident reported not having a bowel movement in about a week. Staff interviews revealed inconsistent understanding and application of the bowel management protocol, with some staff stating that action should be taken after three days, while the DON confirmed there was no formal bowel protocol in place. The facility lacked a written policy or protocol for bowel management, and staff responses indicated variability in how constipation was addressed. The absence of a standardized approach led to delays in intervention and inconsistent administration of PRN medications, resulting in the resident experiencing prolonged periods without a bowel movement despite being at risk due to medical history and medication regimen.
Lack of Competency and Training in Wound VAC Application
Penalty
Summary
The facility failed to ensure that nursing staff providing wound care and applying a wound VAC possessed the necessary competencies and training. A resident with significant medical needs, including respiratory failure, ventilator dependence, diabetes, and a history of unstageable and stage 4 pressure wounds, was dependent on staff for all care. The care plan and treatment administration record required specific wound care interventions, including the use of a wound VAC. However, observations and staff interviews revealed that the LPN responsible for wound care and wound VAC application had not received formal training in these areas and relied on self-directed learning. Further interviews with facility staff, including another LPN, the DON, and the Administrator, confirmed that there was no designated, formally trained wound care nurse, nor was there a facility policy for wound care or wound VAC use. The staff member identified as the wound care nurse performed all wound measurements and VAC changes without formal training, and the facility lacked structured guidance or protocols for these procedures.
Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
The facility failed to ensure that insulin was administered according to physician orders for two residents with diabetes. For one resident, the physician order specified that insulin should be held if blood sugar was less than 150, yet there were eighteen documented instances where insulin was administered despite blood sugar readings below this threshold. The resident's care plan indicated diabetes management with medication as ordered, and the MARs showed repeated administration of insulin when blood sugar was less than 150. Staff interviews revealed that nursing staff did not consistently follow the parameters set by the physician order, with one RN stating disbelief in the necessity of the parameters and another indicating that administration was based on dietary intake rather than the specified blood sugar threshold. For the second resident, the physician order also required insulin to be held if blood sugar was less than 150, but the MARs documented multiple instances over several months where insulin was given despite blood sugar readings below this level. Staff interviews indicated a lack of awareness or understanding of the parameters for insulin administration, with some staff believing that only certain residents had such parameters. The Director of Nursing and Administrator confirmed that there was no facility policy addressing medication administration in these circumstances. Both residents had documented cognitive impairments and required insulin injections as part of their diabetes management.
Improper Catheter Management Leads to Severe Complications
Penalty
Summary
The facility failed to properly evaluate and manage the placement of a urinary catheter for a resident, leading to significant complications. After a routine catheter change, the resident experienced little to no urine output and bloody urine for two days. Despite these symptoms, the facility did not take immediate action, and the resident continued to have bloody urine for an additional two days before being sent to the hospital. Upon hospital evaluation, it was discovered that the catheter balloon was incorrectly placed in the urethra, causing trauma and resulting in a urinary tract infection (UTI). The resident involved had a history of benign prostatic hyperplasia (BPH), heart failure, and diabetes mellitus, and was dependent on staff for toileting hygiene. The resident's care plan included monitoring for signs and symptoms of UTI and ensuring proper catheter care. However, the facility's failure to respond promptly to the resident's symptoms of hematuria and decreased urine output indicated a lapse in following the care plan and physician orders. The hospital findings revealed that the resident had emphysematous cystitis, acute kidney injury, and right lower lobe pneumonia, all of which were exacerbated by the improper catheter placement. The resident's condition deteriorated over several days, with symptoms including abdominal pain, decreased appetite, and general weakness. The facility's inaction in addressing the resident's symptoms in a timely manner contributed to the severity of the resident's condition upon hospital admission.
Inadequate Food Temperature Management
Penalty
Summary
The facility failed to ensure that food was served at adequate temperatures, as observed during a survey. Staff B, a dietary staff member, recorded food temperatures that were below the facility's policy requirements. For instance, the breaded pork chop was recorded at 142 degrees Fahrenheit initially and later at 139.5 degrees Fahrenheit, while the ground pork was at 127 degrees Fahrenheit. These temperatures were below the facility's policy, which mandates that hot foods be served at a minimum of 135 degrees Fahrenheit, preferably at 160 degrees Fahrenheit or higher. Additionally, the pureed pork was initially recorded at 165 degrees Fahrenheit after being placed on the steam table, which was compliant, but other items like the fish fillet and green beans were served at lower temperatures. Resident #29, who was cognitively intact and required assistance with eating, expressed dissatisfaction with the food, citing issues with taste, temperature, and appearance. The resident specifically mentioned that the fish served was not hot. Interviews with the Dietary Manager and Staff B revealed inconsistencies in their understanding of the required food temperatures, with Staff B incorrectly stating that ground meat should be served at 175 to 180 degrees Fahrenheit. The Dietary Manager also confirmed that green beans were served at 121 degrees Fahrenheit, which was below the expected temperature. The Interim Administrator expected food to be served at least 165 degrees Fahrenheit, highlighting a discrepancy between the facility's policy and actual practice.
Inadequate Infection Control During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident. During an observation, a Licensed Practical Nurse (LPN) was seen handling medications, including Levitracetam, Pregabalin, and a stock medication of Calcium with Vitamin D3, with bare hands while preparing them for administration. The LPN touched the medications directly with their hands when placing them into a medication cup and when dispensing from a medication bottle cap. The facility's Infection Preventionist acknowledged that handling medications with bare hands was inappropriate and mentioned a procedure for replacing dropped pills. The Director of Nursing (DON) also stated that dropped pills should be replaced. However, the facility's Medication Administration policy, effective since 2019, did not address this specific concern.
Resident Dignity Compromised by CNA's Inappropriate Conduct
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner, specifically in the case of a resident who was subjected to inappropriate behavior by a Certified Nursing Assistant (CNA), identified as Staff H. The resident, who had intact cognition and was dependent on staff for toileting hygiene, reported that Staff H spoke to her in an aggressive and accusatory manner regarding a personal relationship with another resident. Staff H made derogatory comments about the resident's incontinence and refused to answer her call light, leaving the resident feeling intimidated and verbally abused. The investigation revealed that Staff H had a history of disagreements with the resident and had been reported by other staff members for refusing to provide care and for turning off the resident's call light. Staff H admitted to having a disagreement with the resident and acknowledged making comments about the resident's personal life. Other staff members corroborated the resident's claims, noting that Staff H had been abrasive and had refused to assist the resident, which led to the resident feeling unsafe and uncomfortable. The facility's investigation concluded that the allegations of abuse were substantiated, leading to the termination of Staff H. The investigation found that the abuse was isolated to this employee, and no root cause analysis was deemed necessary. The facility's leadership, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), acknowledged that Staff H's behavior was inappropriate and that the situation should have been addressed sooner.
Failure to Report and Address Alleged Verbal Abuse
Penalty
Summary
The facility failed to adhere to its abuse policy when staff did not notify management of potential abuse concerns involving a resident. Resident #50, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status exam, reported feeling verbally abused by a CNA, Staff H, over a period of 2 to 3 months. The resident described an incident where Staff H made accusatory remarks about her relationship with another peer, which was particularly distressing given the recent death of her husband. Multiple staff members, including CNAs and an RN, were aware of the ongoing issues between Staff H and Resident #50. Staff K, RN, noted that the resident did not want Staff H in her room, leading to a temporary switch of residents between Staff H and another CNA. However, the situation persisted, with Staff H reportedly refusing to provide care to Resident #50 and turning off her call light while she was on the bedpan. Other staff members, such as Staff G and Staff I, witnessed Staff H's aggressive behavior towards residents, including yelling and making derogatory comments. Despite these observations, the staff did not report the incidents to management in a timely manner. The Director of Nursing expressed a desire for earlier reporting and confirmed that staff had been educated on the importance of reporting abuse. The facility's abuse policy required immediate reporting of any allegations of abuse to the charge nurse, who was then responsible for informing the Administrator or designated representative. This protocol was not followed, contributing to the deficiency identified in the report.
Failure to Document Pain Assessment for Resident with Swollen Knee
Penalty
Summary
The facility failed to ensure timely documented assessment of pain and symptoms for a resident with impaired cognitive function and Alzheimer's disease. The resident was reported to have a swollen right knee without redness or warmth, and the ARNP was notified, but no new orders were given. The resident's daughter, who is the Power of Attorney, was also informed. Over the weekend, the resident's condition included swelling, discomfort, and bruising, which was noted by Staff K, a Registered Nurse. Despite these observations, there was no documented pain assessment or treatment plan initiated. The Director of Nursing (DON) indicated that pain should be documented in the progress notes and treated if present, but there was no evidence of a pain score or effectiveness of pain medication being charted. The RN job description requires comprehensive assessments to be performed and documented, which was not adhered to in this case. The lack of timely and thorough documentation and assessment of the resident's pain and symptoms led to a deficiency in meeting professional standards of quality care.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional standards, resulting in a significant weight loss for one resident. Resident #31, who has severe cognitive impairment and requires supervision with eating, experienced a 7.16% weight loss in one month. The care plan for the resident included monitoring for signs of malnutrition and significant weight loss, but the facility did not identify or address the weight loss in a timely manner. The Director of Nursing (DON) acknowledged that the weight loss did not trigger in the facility notes and was not caught by staff, despite the resident's weight loss exceeding the threshold for concern. The Registered Dietitian (RD) and Dietary Manager (DM) were also unaware of the weight loss issue, as it was not flagged in the electronic health record (EHR) system. The RD, who works mostly offsite, had not met the resident and relied on the EHR system to trigger significant weight loss alerts. The DM mentioned that the resident's weight loss might have been discussed in a previous meeting, but there was no documentation to confirm this. The DON later realized that the system had triggered the weight loss alert, but it was inadvertently deleted. The facility lacked a policy regarding weight loss, contributing to the oversight.
Inadequate Staffing for Dining Assistance
Penalty
Summary
The facility failed to provide adequate staffing to assist residents with dining, as observed in the case of two residents with severely impaired cognitive skills. Resident #20 required partial/moderate assistance for eating, while Resident #40 required supervision or touching assistance. During an observation in the dining room, both residents were left without assistance or food for extended periods. Staff N, a dietary staff member, was observed providing minimal assistance, such as offering drinks, but did not ensure that the residents received their meals in a timely manner. Resident #40 requested chocolate milk, but was told to wait, and both residents were observed without food or drink for significant periods. Interviews with staff members revealed that staffing during dining times was inadequate, with CNAs expressing that it was overwhelming and difficult to attend to all residents. Staff G mentioned that they were often told to place residents in the activity room with the television on if they could not be fed promptly. Staff E and Staff F also acknowledged that there were times when staffing was insufficient, leading to delays in assisting residents with dining. The Director of Nursing was unaware of any reported concerns regarding dining staffing, despite the evident issues observed and reported by the staff.
Deficiency in Identifying Triggers for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that targeted behaviors and triggers were identified for the antipsychotic medication olanzapine for a resident, leading to a deficiency in managing unnecessary medications. The resident, who had a BIMS score indicating intact cognition, was diagnosed with unspecified dementia, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and other mood disorders. Despite these diagnoses, the care plan lacked specific information identifying triggers and behaviors that would justify the use of antipsychotic medications. Interviews with staff revealed that while the resident occasionally displayed behaviors such as getting upset and yelling at staff, these were not consistently documented or addressed in the care plan. The facility's policy on antipsychotics, updated in January, did not include documentation requirements for addressing antipsychotic use in the care plan. Staff interviews indicated a lack of clarity and consistency in documenting and addressing the resident's behaviors and triggers. The MDS Coordinator and DON acknowledged that behaviors were only charted when displayed or when there were medication changes, and interventions were not consistently included in the care plan. This oversight in care planning and documentation contributed to the deficiency identified by the surveyors.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors observed during the administration process for two residents. Resident #41, who has moderately impaired cognition, was prescribed Senna Oral Tablet 8.6 mg to be taken as two tablets every other day. However, on the day of observation, an LPN administered Senna Plus, which contains both Senna and Docusate Sodium, instead of the prescribed medication. Similarly, Resident #36, also with moderately impaired cognition, was prescribed Furosemide (Lasix) 40 mg to be taken twice daily for three days and then once daily. During the medication administration, an RN initially gave the resident Lasix 20 mg and later realized the error, subsequently administering an additional dose. The Director of Nursing explained that staff should verify medications by comparing the pharmacy label with the electronic health record, but this protocol was not followed, leading to the errors.
Failure to Provide Timely Dental Care After Denture Loss
Penalty
Summary
The facility failed to ensure timely dental care for a resident who lost her dentures during a choking incident. The resident, who was cognitively intact and had a history of non-surgical orthopedic/musculoskeletal issues and chronic diastolic heart failure, choked on an onion and removed her dentures, which were subsequently lost. Despite efforts to locate the dentures, they were not found, and the resident was placed on a pureed diet, leading to weight loss. The care plan was not updated to address the loss of dentures or the need for replacement. Interviews with staff revealed that the facility had difficulty finding a dental provider who accepted state benefits, delaying the replacement of the dentures. The resident had been seen by a new dental agency starting in March 2024, but prior to this, there was no on-site dental care available. The facility lacked a policy on dentures, contributing to the delay in addressing the resident's dental needs. The resident's diet was eventually changed back to a regular texture, and she regained some weight, but the deficiency in timely dental care remained unaddressed for an extended period.
Failure to Provide Assistive Dining Devices
Penalty
Summary
The facility failed to provide assistive devices for eating, specifically a straw, as per the diet order for a resident with severely impaired cognition. The resident's care plan and physician order indicated the need for a straw to assist with fluid intake, yet observations on multiple occasions revealed the resident was using a regular cup without a straw. Interviews with staff, including the Registered Dietician, Certified Nursing Assistant, and Dietary Manager, indicated a lack of awareness and communication regarding the resident's need for a straw, as outlined in the diet order. The facility's policy on adaptive self-feeding devices requires that such needs be identified and evaluated by nursing, dietary, and therapies. However, there was a disconnect in communication and implementation of this policy, as evidenced by the staff's uncertainty about the resident's requirements and the absence of straws on the menu tickets or in the kitchen. The Director of Nursing acknowledged the lack of clarity on how this information should be communicated, highlighting a deficiency in ensuring the resident received the necessary assistive devices for dining.
Inappropriate Antibiotic Use Due to Symptom-Based Prescribing
Penalty
Summary
The facility staff failed to adhere to infection control practices aimed at reducing unnecessary or inappropriate antibiotic use. The facility's Antibiotic Report for January, April, and May 2024 documented instances of inappropriate antibiotic starts, with ten residents affected in January, eight in April, and five in May. The Infection Preventionist (IP) indicated that antibiotics were often prescribed based on symptoms without waiting for test results, leading to residents continuing antibiotic treatment for the full duration of the prescription even when cultures returned negative. The facility's Antibiotic Stewardship Policy, dated November 28, 2017, outlines the goal of promoting appropriate antibiotic use to maximize treatment outcomes and minimize unintended consequences. Despite this policy, the practice of prescribing antibiotics without confirmed test results contributed to the deficiency. The IP tracks all antibiotics prescribed, including orders, diagnostic testing, and results, but the practice of prescribing based on symptoms persisted, contributing to the inappropriate use of antibiotics.
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What surveyors actually found near you
We read the 34 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montrose Health Center | 7.3 mi | ★★★★★ | 4 | 0 |
| West Point Care Center Inc | 8.1 mi | ★★★★★ | 4 | 0 |
| Aspire Of Donnellson | 10.8 mi | — | 0 | 0 |
| River Hills Village In Keokuk | 13.4 mi | ★★★★★ | 6 | 0 |
| Mississippi Valley | 14.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.